Information Collection

Crisis Next Door Campaign Assessment

IC 238053 under ICR 201806-0920-001 · OMB 0920-0572.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0572 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0572 Crisis Next Door Campaign Assessment Form and Instruction
0920-0572 Crisis Next Door Screener Attachment 3 - Screener_20SEP2019.docx Form and Instruction
0920-0572 Crisis Next Door Questionnaire Attachment 3 Survey Questionnaire Revised 09OCT2019.docx Form and Instruction
Link to Crisis Next Door (CND) Videos.docx Crisis Next Door (CND) Videos IC Document
Attachment 2 - Consent Form_20SEP2019.docx Consent Form IC Document
HMTSExpeditedReviewForm - Crisis Next Door_FINAL.pdf HMTS Expedited Review Form IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Crisis Next Door Campaign Assessment	Agency IC Tracking Number:	09209-0572-19BRS

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0572	Crisis Next Door Screener	Attachment 3 - Screener_20SEP2019.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0572	Crisis Next Door Questionnaire	Attachment 3 Survey Questionnaire Revised 09OCT2019.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,315	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6,315	6,315
Annual IC Time Burden (Hours)	774	774
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crisis Next Door (CND) Videos	Link to Crisis Next Door (CND) Videos.docx	10/09/2019
Consent Form	Attachment 2 - Consent Form_20SEP2019.docx	10/09/2019
HMTS Expedited Review Form	HMTSExpeditedReviewForm - Crisis Next Door_FINAL.pdf	10/09/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.